ISSUE 05ISSUE September 2020
This issue Last Month’s Slides P.1 Last Month’s Monthly Case study P.1 Red Cell morphology P.2-3 Slides Monthly Quiz P.2 Morphology Posters P.3
August 2020 Slide Summaries Monthly Digital Case study August 2020 Slide 6 Slide 1 Generally normal film – all 5 normal WBC cell types make it a good Presentation training slide Female (65 years old) In Intensive Care Unit Slide 2 Generally normal film – some FBC Results platelet aggregates WBC 14.8 (10^3/mm3) Neutrophils 53.0% RBC 3.06 (10^6/mm3) Lymphocytes 17.4% Slide 3 HGB 91(g/L) Monocytes 6.1% Generally normal blood film, mild HCT 27.5(%) Metamyelocytes 12.2% basophilia MCV 90 (fL) Myelocytes 8.7% MCH 29.9 (pg) Promyelocytes 0.9% Slide 4 MCHC 33.3 (g/dL) Blasts 1.7% Lymphocytosis with large granular PLT 57 (10^3/mm3) lymphocytes and some atypical lymphocytes in a 19- year old male. NRBCs 20/100WBCs Glandular fever screening recommended Slide review Leucoerythroblstic blood film with an occasional blast. Neutrophils are generally left shifted but without Slide 5 toxic granulation. Basophilia, myelocytes and The red cells show a variety of dyscrasia. Schistocytes occasional blast. Possible and the occasional spherocyte indicative of haemolysis. myeloproliferative disorder Basophilic stippling and the occasional Howell-Jolly Body.
Slide 6 The blood film confirms the thrombocytopaenia Patient in intensive care Leukoerythroblastic blood film. Thrombocytopaenia, anisocytosis, Diagnosis schistocytes, polychromasia and No clinical details however, given the patient’s location and in the the occasional spherocyte. absence of any other clinical details, the blood film is suggestive of Basophilic RBC inclusions Sepsis with potential haemolysis, possible DIC. Monthly Morphology Red Cell Quiz Inclusions in Can you identify this Peripheral Blood cell?: An overview of laboratory findings Introduction Red blood cells or Erythrocytes, are the most common cell type. The morphology of a normal red cell is a bio-concave disc, lacking a nucleus or organelles, with a central area of pallor. In general, red cells viewed under a microscope will have a fairly uniform variation in size, shape and colour. A variation in any of these features could indicate an abnormal red cell morphology. Red cell inclusions may arise in various sources. The correct identification of these inclusions is extremely important for providing information on metabolic, physiological and also pathogenic conditions which may be effecting the patient.
The most commonly seen red cell inclusions are:
What does this Indicate? Basophilic Stippling Basophilic stippling, or punctate basophilia, appears in red cells as blue, fairly evenly spread fine dots throughout the cytoplasm of the cell. The stippling can be Last month’s cells: described as “fine” or “coarse”. The stippling is due to spontaneous aggregation of ribosomal RNA in the cytoplasm of red cells. These aggregates then stain and are visible when using routine haematology stains. Basophilic stippling commonly arises due to one of two pathological processes: Dyserythropoietic states- infiltrated Bone marrow, Haemoglobinopathy, Pathways of RNA breakdown are impaired- due to poisoning by heavy metals, classically lead or arsenic, or pyrimidine 5’ nuclease deficiency.
Howell-Jolly bodies Identified by small blue/purple fragments which are generally rounded in shape. Howell-jolly bodies are usually single and centrally placed within the red cell with a relatively large size compared to other The blood film shows a red inclusions. The colour and position reflects their origin cell with a Cabot ring and a as non-functional nucleus fragments which have Howell-Jolly body Remained in the cell when it left the bone marrow. The presence of these inclusions is commonly In this case, the patient was associated with the absence of the spleen or if the function of the spleen is impaired.in cases displaying a myelodysplastic such as coeliac disease, bone marrow transplant or pregnancy. picture with abnormalities in all cell lines and Pappenheimer Bodies circulating Pappenheimer bodies are basophilic iron-containing granules. Non-nucleated red micromegakaryocytes. cells containing pappenheimer bodies are known as siderocytes. These inclusions occur because of aggregates of iron from the cytoplasm, or within the For more on red cell mitochondria. A nucleated cell with the same inclusion is known as a sideroblast. Pappenheimer bodies differ from basophilic stippling in that they inclusions, see the main are a denser blue and the granules are courser and there are usually article. less of them and they are usually seen at the edge of the cell
(see over for illustration). Red Cell Other News QSP 2.0 Inclusions in Available now!
Peripheral Blood Options for a single Continued from page 2… operator or site license which allows Staining with Prussian blue will confirm the presence of siderocytes with a blue reaction, up to 10 concurrent if in sufficient amounts. users
The presence of siderocytes may be connected to haemolytic anaemia- increased iron turnover can lead to siderocyte formation, or abnormal haem synthesis, where iron Bibliography accumulates in the RBC if haemoglobin production is hindered. QSP August 2020
Heinz Bodies Hoffbrand’s Essential Heinz bodies appear as small, round inclusions within the red cell, but are not visible Haematology 7th edition when using Romanowski dyes. They are visualised more clearly with the use of Wiley Blackwell supravital staining such as methylene blue.
Their presence on a blood film indicates oxidative damage to the haemoglobin component molecules, often through oxidant damage by administered drugs.
Conditions associated with Heinz bodies include alpha-thalassaemia or haemolytic anaemia and G6PD deficiency. Heinz bodies can also be present in chronic liver disease. Editorial Team Kelly Duffy Mandy Campbell Conclusion Shubham Rastogi
In conclusion, red cell inclusions are nuclear or cytoplasmic aggregates which can be stained. The presence of these inclusion bodies is almost always indicative of some pathological abnormality and is therefore crucial that the correct identification.
About us Morphology Posters – Free of charge HORIBA UK Limited Kyoto Close HORIBA Medical have produced Moulton Park two posters; Haematopoiesis, an Northampton, UK illustrated chart of cell development, and NN3 6FL Morphological abnormalities of red blood cells. HORIBA Medical Parc Euromédecine, 390 Rue du Caducée, These are available Free of Charge as high- 34790, France resolution PDF files for printing locally – they look particularly good in A2 size. www.horiba.com/medical
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